Diagnostic Accuracy of Intraoperative Neurophysiologic Monitoring in Spinal Deformity Surgery: Systematic Review and Meta-Analysis.

Study DesignSystematic review and diagnostic accuracy meta-analysis.ObjectiveTo evaluate the diagnostic accuracy of intraoperative neurophysiologic monitoring (IONM) for detecting postoperative neurologic deficits in spinal deformity surgery and assess performance across monitoring modalities.MethodsA systematic review of PubMed, Embase, and Web of Science (2000-2026) was performed in accordance with PRISMA guidelines. Studies reporting intraoperative neuromonitoring and postoperative neurologic outcomes were included. Diagnostic accuracy metrics were calculated from contingency tables and pooled using random-effects models. Subgroup analyses were performed by monitoring modality.ResultsA total of 43 studies were included in the systematic review. Of these, 38 had constructable 2x2 tables and contributed to the specificity and false-positive rate analyses, while 36 contributed to the sensitivity, false-negative rate, and diagnostic-odds ratio models. Pooled sensitivity was 90.1% (95% CI, 83.8-94.2%), and pooled specificity was 95.4% (95% CI, 93.0-97.0%). The diagnostic odds ratio was 206.8 (95% CI, 92.8-460.9). Heterogeneity was observed (I2 = 56.7% for sensitivity and 95.3% for specificity). Sensitivity and specificity remained broadly comparable across conventional monitoring modalities, and between-modality differences were not statistically significant.ConclusionsIONM demonstrates high specificity and strong sensitivity for detecting neurologic injury in spinal deformity surgery. Performance was similar across conventional modalities, although sensitivity and false-negative rates varied across studies. These findings support the continued use of IONM as an intraoperative safety tool while highlighting the need for standardized reporting and improved interpretation of monitoring signals.